PASSING THE PSYCHOTHERAPY WRITTEN CASE

Transcription

1 PASSING THE PSYCHOTHERAPY WRITTEN CASE

2 Passing the Psychotherapy Written Case (PWC) Overview PWC in the era of the CBFP EPA s & WBA s PWC: 3 Stage Formative Component Trends in passing rates PWC: Summative Component -> Preliminary considerations -> Choosing a psychodynamic model -> Using the 7 College assessment domains Bringing it all together

3 The Psychotherapy Written Case (PWC) in the era of CBFP The (2012) CBFP is a more outcome & competency orientated framework based on CANMEDS Model for the Medical Expert Reinforces need for a psychological understanding of all our patients Reinforces the Psychotherapy Written Case central role in psychotherapy training Uses EPA s & WBA s in psychotherapy training Uses the Formative Case Discussion Assessment component

4 The PWC in the era of CBFP Standards Completion of the PWC is not a barrier to entering Stage 3 of training (average submission after 24 months in training) but is required for entry for Psychotherapy AT Certificate Will be assessed at Junior Consultant Standard Competence of trainee as a therapist is not the major focus of assessment PWC marking pro-forma is aligned with CBFP Developmental Descriptors (see list on RANZCP website)

5 Entrustable Professional Activities (EPA s) & Workplace Based Assessments (WBA s) EPA s & WBA s have been introduced as an integral part of the CBFP To aid trainees with structure, guidance and tools that help in both formative and summative components of the assessment process Requires a number of new rules, forms and processes

6 EPA s EPA s are mandatory summative assessments They consist of specialised tasks that trainees must perform competently in order to progress to the next stage of training Each 6 month rotation requires completion of 2 EPA s

7 EPA s There are 3 categories of EPA s over 3 Stages of Training General Psychotherapy (x3 over Stage Two & Three, x10 in Stage Three) Specialist Rotation (CL, Child, Addiction, Old Age, Forensic etc) Fellowship (FELL) EPA s can be attained in any area of practice rotation ( Foundational ) Area of practice (AOP) EPA s can only be attained in the relevant area of practice ( Advanced )

8 EPA s through Basic, Proficient & Advanced Stages of training Stage 1 BASIC Stage 2 PROFICIENT Stage 3 ADVANCED 4 General (2 Mandatory) EPA s 4 General Psychiatry EPA s 2/3 Psychotherapy EPA s Supportive Psychotherapy Managing Therapeutic Alliance CBT for Anxiety 24 Specialist Rotation based EPA s Additional General Psychiatry EPA s Additional Psychotherapy EPA s (4 FELL & 6 AOP) Use of Supervision (FELL) Assessment & Planning (FELL) Management of Psychotherapy (FELL) Research Skills (FELL) Presentation Skills Supervisory Skills

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11 Using WBA s WBA s are a formative assessment tool that has been introduced as part of the CBPF to provide greater structure to the supervision experience 4 WBA tools are approved for use in the CBFP Each WBA tool specifies a number of options on which to focus the assessment

12 Case Based Discussion Observed Clinical Activity Initial assess 4 WBA TOOLS Mini Clinical Evaluation 20 min clinical encounter Professional Presentation

13 How are EPA s & WBA s linked? WBA s provide a mechanism for structured feedback in the formative assessment of competence in typical work settings Supervisors use WBA tools, together with other information, to assess whether a trainee can attain a particular EPA A minimum of 3 WBA s must be used in the assessment of each EPA Bi-National Committee will be publishing summary booklet in near future

14 EPA s, WBA s & the CBFP WBA S Via 4 Prescribed Tools (PROVIDES STRUCTURE TO SUPERVISION) = FORMATIVE ASSESS Choose/Use a Tool 1.Case Based Discussion 2. Mini Clinical Evaluation 3. Observed Clinical Activity 4. Professional Presentation EPA S General, Psychotherapy, Specialist = SUMMATIVE ASSESS FELLOWSHIP COMPETENCIES LEARNING OUTCOMES (PRESCRIBES MINIMUM EXPECTATIONS)

15 The Psychotherapy Written Case in the era of CBFP FORMATIVE ASSESS (X3 Case Discussions) PSYCHOTHERAPY WRITTEN CASE SUMMATIVE ASSESS (Case Writeup) 7 Domains

16 The PWC in the era of CBFP Formative Component Trainees must participate in 3 (formative) case discussions with their psychotherapy supervisor during the therapy process Psychotherapy case discussion form to be submitted for each of the 3 phases Encourages reflection on treatment progress and provides opportunity to receive constructive feedback in order to draft the case out as you go Shapes out early, middle and late phase by facilitating/structuring discussions with supervisors Highlights/explores developmental milestones in the therapy Do prep work and bring a draft

17 Case selection CASE DISCUSSION FOCUS Early Phase Suitability of chosen modality Assessment/MSE examination Initial formulation Understanding theoretical frameworks/therapies Treatment Planning

18 CASE DISCUSSION FOCUS Middle Phase Therapeutic progress & process issues Key episodes Reflect on nature of the therapeutic relationship Treatment dilemmas/emerging issues (transference, boundaries, termination) Understanding and application of theoretical framework

19 CASE DISCUSSION FOCUS Late Phase Reformulation Termination Evaluation of the therapy Specific learning points from the experience Review of appropriateness of chosen therapeutic model Reflection on supervision

20 Using the formative Case Discussion Assessment component Early Phase CASE DISCUSSION 1 Middle Phase CASE DISCUSSION 2 F E E D B A C K Late Phase CASE DISCUSSION 3 3 PILLARS OF THE PWC

21 Purpose of the Formative Case Discussion Assessment component IMPROVE SUPERVISION PROCESS via Structure Feedback Guidance IMPROVE SUPERVISION EXPERIENCE & EFFECTIVENESS IMPROVE PWC PASS RATES PSYCHOLOGICAL METHODS COMPETENCY

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23 Passing The PWC General Trends & Pitfalls What are the overall pass trends? Pre 2004 pass rate ~ 90%, since then ~ 75% 50% Which sections fail? Assessment/MSE, Formulation & Management probably worst

24 Pass Rates (all cases) since % 90% 80% 70% 60% 50% psychotherapy all cases other cases pre 2004, then first presentation from

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27 Which Section Fails? Unsatisfactory ratings for Psychotherapy Case History marking March 2006 to Nov Percentage of cases Mar-06 June-06 Sep-06 Dec-06 Mar-07 Jun-07 Aug-07 Date of submissions Nov-07 Mar-08 May-08 Aug-08 Nov-08 Initial Assessment and Mental State Examination Management Plan Discussion Adequate Formulation Clinical Progress and Communication/Liaison

28 Written English English Standards in Psychotherapy Case Histories March 2006 to Nov 2008 Percentage of submissions Date of submissions Adequate English standards Inadequate English standards

29 Pattern in 2012 cohort (n=11) Domain Satisfactory Rate (%) Unsatisfactory Rate (%) Assessment/MSE 9 91 Formulation Management Clinical Progress Supervision 91 9 Communication Discussion 73 27

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31 The PWC in the era of the CBFP Summative Component Largely unchanged -> its purpose and basic principles remains intact SOCIAL PSYCHOLOGICAL BIOLOGICAL

32 The PWC in the era of the CBFP Summative Component Reinforces integral role of competency in psychological methods for all Psychiatrists (and relevance for all patients) Skills not only pertinent for those planning to work as psychotherapists but as an integral aspect of a Psychiatrist s expertise necessary in: The general setting or private practice The hospital environment (including C-L psychiatry)

33 The PWC in the era of the CBFP Summative Component Reinforces the PWC as the main method through which psychotherapy skills are assessed Only component of CBFP in which the trainee s capacity to prepare & submit a formal report is assessed Necessary in communicating with referring doctors or in constructing medico-legal reports

34 The Purpose of the PWC Conduct psychological therapy Communicate in writing their assessment, formulation, management KEY CAPACITIES Integrate theoretical & clinical knowledge in a discussion Reflect on patient relationship & supervision experience

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36 PSYCHOTHERAPY-WRITTEN-CASE.aspx

37 Preliminary Considerations Selection of Patient ->Long case is not the same as long-term psychodynamic psychotherapy (ie time limited) -> Good assessment crucial & identify a dynamic focus -> Modest expectations of change

38 Preliminary Considerations Orientate to College requirements early on Refer to RANZCP PWC Mark Sheet and Link 45 on College website Remember de-identification, confidentiality, consent Consider keeping separate process notes or note book with milestones to act as guidelines Use early phase formative case discussion to set off on right path Drafting essential

39 Preliminary Considerations Choosing a Psychodynamic Modality Psychodynamic psychotherapy uncovers the unconscious patterns of object relations (interpersonal relationships/attatchments), conflicts and desires that cause symptoms such as anxiety and depression Modalities Freud & Ego Psychology Klein & Object Relations Theory Kohut & Self Psychology Bowlby & Attachment Theory Postmodern Schools (Intersubjectivity, Relational)

40 Preliminary Considerations Choosing a Psychodynamic Modality Despite profound transformation since Freud, core principles derived from psychoanalysis remain Frame and boundary setting A developmental perspective Psychic determinism Complex meanings of symptoms, behaviours and motivations The unconscious The relationship Transference/counter-transference Resistance Working through

41 Preliminary Considerations Choosing a Psychodynamic Modality Multiple modes of therapeutic action that varies from patient to patient Continued emphasis on the 2 person nature of the relationship in therapy Trainee needs to demonstrate a link between patient s needs and the modality chosen [Gabbard, G. O. (2005): Major modalities: Psychoanalytic/psychodynamic. In: Gabbard, G. O., Beck, J. S. & Holmes, J. (Eds.). Oxford textbook of psychotherapy(pp. 3-13). (Oxford/New York: Oxford University Press)]

42 Choosing a Psychodynamic Modality Qualitative & quantitative factors Choice of modality can also be guided by severity of disorder and level of engagement that the patient is capable of Coherence, relational & psychosocial functioning, affect regulation Philip Graham and Leo van Biene s Hierarchy of Engagement model based on the Hughlings Jackson Hierarchy of Consciousness (The Self in Conversation, Vol VI, Editor Pauline Nolan, 2007) Nancy McWilliams/PDM P Axis takes into account: (1) Level of personality organisation (healthy->neurotic->borderline) (2) Personality patterns and then temperamental, thematic, affective, cognitive and defensive patterns

43 EXPANDING COLLABRATIVE INTERSUBJECTIVITY (NEW FORMS OF RELATEDNESS) ELABORATING OF DEFENSIVE CONFIGURATIONS (INTERPRETATION) IDENTIFYING & TRANSFORMING TRAUMATIC SYSTEMS FOSTERING OF THE PERSONAL (REFLECTION, MENTALISATION) PROVISION OF SAFETY

44 Choosing a Psychodynamic Modality MULTIPLE THERAPEUTIC MODES LIKELY: 2 FUNDAMENTAL PILLARS FOSTERING INSIGHT Awareness of repetitive pattern, conflicts & defences Coherent self-view Better judgement Acceptance Cognitive restructuring THERAPEUTIC RELATIONSHIP ITSELF Containment Internalising therapist s capacity to mentalise/self-reflect Internalisation process modifies representations of self & others etched in childhood

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46 The Summative Assessment Component of the PWC The 7 College Assessment Domains The knowledge, skills and attitudes gained through the process of therapy are then communicated/reflected in the written case The written case is then assessed within 7 College Assessment Domains (reflected in the structure of the PWC Marking Sheet) Familiarising yourself with the structure of 7 Assessment Domains is critical in passing the summative component of the PWC Attending to structure then frees you up for flexibility & exploration

47 The Summative Assessment Component of the PWC The 7 College Assessment Domains Assessment Management Clinical Progress Reformulation Supervision Communication Discussion

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52 De-identification & Presentation Importance of written English & clarity

53 Presentation Basic Principles in Writing-up the PWC Structure Organise data & presenting it in a logical manner Communication is key: Coherence of thoughts & written language Professional English (the expected standard is that of a formal report) Attention to spelling, grammar, layout & editing (over-use of computer spell-checks) Candidates fail on written English even those for whom English is their first language Obvious gross repetitiveness Consistency with names, ages, dates Encourage having it proof read by a 2 rd supervisor, DoT, colleague, 3 rd party!

54 Presentation Basic Principles in Writing-up the PWC Content A story about the patient and their clinical involvement in a process that evolves over time Capture & convey the essence of the patient & the therapeutic relationship as it unfolds Demonstrate the ability to make a sophisticated psychodynamic formulation Demonstrate knowledge of psychotherapeutic principles and theoretical underpinnings Discuss/reflect the experience and role of supervision

55 Assessment Main problem area in Summative Assessment Component 7/9 criteria require proficient standard rather than junior consultant standard Trainees must include comprehensive psychiatric history in standard format Psychiatric history often lacking clinical acuity (a narrative but omitting symptoms of anxiety, mood etc) This is a psychiatric psychotherapy case See HETI resource Personal/developmental history must be detailed enough to substantiate formulation & management plan

56 Assessment Comprehensive MSE relevant to the process of psychotherapy with that patient MSE often brief, unelaborated as patients viewed as normal relative to hospital patients Need to demonstrate observational MSE skills (not Speech: No Formal Thought Disorder identified ) Inadequate risk assessment Should include physical health and investigations Often not included Collection of additional information Include any organic factors Diagnosis, DD using recognised classificatory system Diagnosis and DD poorly justified

57 Assessment Initial Formulation Developed at the time of initiating therapy Explaining why this person presented in this way at this time Not addressed 2 new criteria emphasising deficits in past cases Understanding the risks/impact of treatment Critical appraisal & reflection

58 Management Plan Demonstrating relevant bio-psycho-social, spiritual/cultural issues Biological and socio-cultural issues not considered Discussion of ongoing biological treatments (eg medication) omitted Clearly informed by the formulation? Involvement of other health professionals?

59 Management Plan Justification of psychotherapy usage Inadequate exploration of goals and expectations of patient/therapist and way in which therapy was negotiated with patient Justification of the psychological model used Consideration of other modalities, potential risks and limitations of model used, not discussed Stick to one model for coherence (universality not pastiche) Consider potential difficulties arising (new addition)

60 Clinical Progress Review of the psychological processes experienced using an appropriate theoretical model Inadequate discussion of experience of working with chosen modality (ie therapy described but not integrated with the therapeutic model employed) Relationship with patient Essence of therapeutic relationship not conveyed (candidate depicts themselves as passive observer rather than active participant)

61 Clinical Progress Self reflection, limitations and appropriate self criticism of trainee Lack of self reflection/self awareness Summary with a capacity to prioritise and identify key episodes in therapy Poor prioritisation of material (eg lengthy description of early sessions but then last 20 sessions dealt with briefly) Reformulation Often missing hence now given separate section Termination No discussion of termination issues (particularly where therapy was ongoing)

62 Clinical Progress 3 New Criteria added Issues of boundaries & ethical dilemmas Sophisticated use of psychological language Use of videoconference technology

63 Reformulation Reflect increasing knowledge/experience of the patient and the process of therapy Little evidence of re-formulation Supervision Was the role of psychotherapy supervision adequately explored (interaction and processes)? Communication/Liaison Communication with other health professionals and impact on therapeutic relationship Only mentioned if a central event/issue

64 Discussion Evaluation of the therapy and its significance Reflection on the theoretical model used and its usefulness/appropriateness Critique/shortcomings of therapy or modality used often missing (ie therapy appropriateness/usefulness) Reflection/critique of the existing theoretical knowledge base Reflection particularly poor if therapy did not go well or patient selection was poor

65 Other Resources Supervisor, DoT, Committee for Examinations members HETI Complete Clinical Assessment Selzer & Ellen s Formulation for beginners article RANZCP website including EPA Handbook and Forms, Psychodynamic Psychotherapy Reading List South Western Sydney Psychiatry Training Network (SSWPTN) website -> swslhd.nsw.gov.au (Hierarchy of Engagement article) Gabbard, G. O., Beck J., & Holmes J. (Eds). Oxford textbook of psychotherapy. Oxford University Press McWilliams N. Psychoanalytic Diagnosis. Guilford Press. Psychodynamic Diagnostic Manual. PDM Taskforce, 2006.

66 COHESIVE STORY OF THE THERAPY JOURNEY PASSED THE LONG CASE 3 CASE DISCUSSIONS HIGHLIGHTING IMPORTANT MILESTONES AWARENESS OF COMMON PITFALLS ORIENTATE TOWARDS 7 COLLEGE ASSESSMENT DOMAINS INTEGRATE ACADEMIC & CLINICAL KNOWLEDGE WITH PERSONAL EXPERIENCE CLEAR WRITTEN COMMUNICATION

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